Application for Well Permit

Brazoria County Ground Water Conservation District 111 E. Locust St. Building A-29, Suite 140 Angleton, TX 77515 Phone: (979) 864-1078 Fax: (979) 864-1079

Instructions:  Submit this form for each aggregate well system. Send an application fee of $100.00 for each well within seven (7) days to the above address. State of Texas Well Report is due within 90 days of drilling of new well.

General Information Needed:  (Do not put any driller or engineer address information in General Information section if you are not the owner of the well)
Well Owner:
Attention:
(If correspondence is being sent to a large organization, insert the specific person's name to whom you wish it directed. If self, enter self.)
Mailing Address:
City:	State:    Zip:
Owner's Phone #:	Ext.:
Health Dept. I.D.: (if applicable)

Well Data:
Physical Location of Well:
Latitude:	Degrees:		Minutes:		Seconds:
Longitude:	Degrees:		Minutes:		Seconds:
Total Depth:  ft.    Depth to First Screen:  ft.    Inside Diameter of Casing:  in.    Expected Production During the Next Twelve Months:  Million Gallons.     Amount of Surface Water purchased in previous Twelve Months:  Million Gallons.       Select intended use:     Public Supply - Wells used for retail or wholesale water supply, or if well is used by at least 25 individuals at least 60 days out of the year, or combined systems serve 15 or greater. Commercial - Wells used by commercial or business establishments for potable or sanitary needs. Industrial - Wells used as part of an industrial process or in the manufacturing of a product. Agricultural - Wells used in production of food or fiber commodities grown for resale or commercial purposes including wholesale nursery growers and wells used for livestock operations. Other - Wells used for other non-exempt uses such as subdivision lake or pond maintenance, irrigation of golf courses, landscapes, parks, etc. Provide detailed description of intended use.  If commercial or industrial, describe type of business, number of employees, type of product produced or sold, etc.  If for new development, include construction start date.  If agricultural, include crop type and acreage.     Describe any other water supply available at this location.  For example, is there a municipal water line available for potable service or a canal or other raw water source for non-potable uses?     Status of this well as of given date:   Being Drilled Existing Awaiting permit to begin drilling Year drilled or being drilled:     Aggregation:  If this well is to be placed in aggregate with other permitted wells, give lead well number of aggregation:     Does the "well owner" own any other well in Brazoria county?   Yes No If yes, explain:    Is this well replacing an existing well?   Yes No If yes, give well no. of well being replaced   and length of time owned or leased:  If this well is a replacement well, what will be the status of the old well? Not a Replacement Well Capped Plugged In Use If status of old well is "In Use", explain:        Applicant/Agent Name:    Applicant/Agent Phone:    Ext.:   Please enter your e-mail address:      Please re-enter your e-mail address:      If this is an emergency application, you must also include reasons for the emergency  and a fee of $100.00 for emergency applications for each well to the above address. Such action is: (check those applicable)    An emergency need for groundwater exists. Reason for Emergency: (Why you cannot wait approximately 60 days for your Permit to be processed)